Medical emergency room patient record software has been developed to ease the collection, processing, and use of medical records in various settings, such as a hospital emergency room. One problem with such software is the need to train and motivate physicians and other medical staff to promptly and accurately enter patient data into a system running the software.
Physicians have been trained to make paper records of their work, often using a pen and a blank sheet of paper, a preprinted form having blanks for recording information, or a dictating machine to record their initial notes. The physicians subsequently need to follow up or be followed up in some fashion to translate their informal notes into electronic records on a permanent recording system.
It is often difficult to train and motivate physicians accustomed to making paper notes to enter their original notes directly on the medical charting software, as by using a computer keyboard, a personal digital assistant (PDA), a tablet computer, or other electronic media. One value of the present invention is to allow a physician to enter paper notes in the traditional fashion, in a way that makes an immediate, permanent, electronic record entered in the medical charting software.
Systems have been developed for automatically converting handwritten informal notes, as on a preprinted form or even a plain sheet of paper, into formatted electronic records. For example, Anoto has developed text and image recording forms based on a sheet of paper with a subtle grid with a pattern of dots or “glyphs” printed on it. The pattern is different on each part of the paper, with a high degree of resolution, so an electronic image of a particular portion of the paper can be identified as such by decoding the pattern recorded as part of the electronic image.
The paper is written upon using a pen that includes a digital camera to frequently record (generally many times per second) where the pen is, with respect to the paper. The location of the pen is determined by recording an image of a small portion of the grid of glyphs in the vicinity of the pen, and immediately or later transmitting the images to a computer system that reads the glyphs and determines. the location of the pen on the grid from moment to moment. The computer system can determine what is written and where on the page it is written by processing the photographs, as by reading the handwriting reconstructed from the positions and movements of the pen. Alternatively, the reconstructed handwritten entries can be stored as images, as in a portable document format (.pdf), tif, or other image file. See e.g. U.S. Pat. No. 6,502,756.
One currently available physical arrangement of the system is that the pen is cordless, it saves a record of the marks on a page when the “magic box” on the page is marked, and when the pen is inserted in a cradle or holder it downloads the pages to a computer and generates on the computer a duplicate of what was marked on the paper. Another currently available physical arrangement of the system is that the pen is cordless, includes a transmitter, and downloads to a remote computer a record of the marks on the page when the “magic box” on the page is marked. The computer can optionally optical character read (OCR) any written text or can convert marks on a particular area of the paper (as checks on a form with check boxes or handwriting in a data entry box) to electronic data indicating the selection or information recorded on the form.
One problem that remains with a system based on this technology is how to associate a particular handwritten record with a particular patient. Often, a busy physician does not fully or legibly record patient information such as a full name, a social security number, a patient number, or other unambiguous recordkeeping information identifying a unique patient in his or her initial notes. The physician may later have doubt respecting which patient corresponds to which notes, in this situation. The doubt respecting which patient is the correct one will ordinarily increase as time elapses, so it is important to identify and match a record that lacks identifying information with the appropriate patient in a timely manner.
Another problem in the art is how to communicate detailed discharge instructions to a patient after the patient has been treated.
Modern hospitals find it necessary to discharge patients as soon as possible, which means that they are often sicker and require more information that they can take with them after they are discharged from the hospital than would have been true years ago. Often, the physician is not available at the time of discharge, and even if available may not have the time to prepare custom written instructions-giving the patient exactly the needed information.
Hospitals and physicians have addressed this problem in the past by giving patients preprinted, generalized stock instructions based on the general nature of the complaint leading to hospitalization. Such instructions are general in nature, and may contain much the patient does not need to know and too little of the specific information the patient should know.
Still another problem in the art is how to minimize the time required to properly prepare a medical record reflecting the work done to diagnose and treat the patient. Medical diagnosis requires the routine collection of many different kinds of data reflecting the patient's condition, such as body temperature, blood pressure, the presence or absence of many different disease symptoms, etc. The physician then focuses mainly on the abnormal data—what is wrong with the patient—to reach a diagnosis. Once data is determined to be normal, it has little role in the diagnosis.
Since for most patients most of the data is normal at any given time, much of the data collected turns out not to bear on the problem at hand. Yet, to maintain a proper, unambiguous medical record, it is important to record all of the normal data too, as normal data shows the basis for ruling out a wide variety of possible diagnoses. Recording all the normal data requires a lot of professional time, which is valuable and scarce. Another problem in the art is how to communicate to a clinical user that it is important to document findings specifically intended to avoid ambiguity which encourages litigation, such as normal findings.
One technique that has been developed for addressing this problem is charting by exception. When one is charting by exception, normal data is not charted, and those reading the chart assume that all normal data was in fact collected and found to be normal, although it is not explicitly recorded.
One problem with charting by exception is that many people are reluctant to believe that data that has not been recorded has actually been measured. For example, many nurses have traditionally been trained to assume that anything not charted has not been done. Also, insurance companies often pay different amounts for medical services, depending on what work was done, and may question whether all the normal results implied by charting by exception were actually observed.
Another problem with charting by exception, particularly for physicians who have some discretion to decide how they will evaluate a patient, is that different physicians may normally collect different data while evaluating the patient. Charting by exception assumes that an established schedule of data has been evaluated, and that if some item of the established schedule is normal, it is not explicitly charted. If a medical professional does not check one or more established items, and charting by exception is applied, a false assumption will be made that the professional has checked the omitted item. On the other hand, if a particular professional routinely collects data beyond the established schedule (which may be justified, for example, by a medical discovery not yet reflected on the standard chart or the experience of the physician that additional information would be useful), an assumption will be made that this additional data was not collected. In this case, the medical record is less complete than it should be.
Therefore, a continuing problem in the art is how to reduce the amount of time required to record normal data that has been collected, while maintaining a full and correct record of the data collected in the course of diagnosing and treating the patient.